How Primary Care Reduces Health Care Costs in the Long Run
Now that the teeth gnashing over health care reforms has been ongoing for two years, before the lifelines are cut on financing health care for the forty-nine million uninsured population, let’s examine the health care continuum for the impact of a failure-to-fund the health insurance subsidies. One of the things that is missing from many discussions and assertions about the 2010 U.S. health care reforms are which systems need to be changed in order to reduce the long term cost of American health care. And when I say reduce, I mean reduce the cost increases in providing health care to an aging population. It is essential the U.S.A. get the per-capita cost of its health care in-line with other nations, as it gobbles funds that could be used for education, capital investments for industry, and other economy building activities. The country will need to make substantial investments in k-12 education as well as building a more energy efficient infrastructure to have a chance at competing with global leaders for competitive contracts, as Germany and other countries have done. This article addresses the components of American health care that are impacted by the 2010 mandates and what it means for managing patient care over a lifetime.
Perspective
Rather than thinking of health care as a commodity that deserving people get, for those who have worked where it is provided by an employer or who qualify for Medicare by virtue of accumulating enough quarters of eligible earnings, or military personnel, please consider it a part of the national infrastructure for a moment. A healthy population is necessary to obtain optimal output from workers, students, and for the care of our families. The provision of health care may be considered a utility. Utilities are measured by their output, the efficiency of their output, and the cost of producing the service. Measuring quality across the United States health care system, which is disparate and complex, is a major challenge in building higher efficiency into American health care.
Measuring Health
From the moment we are born until we die, we are introduced to various aspects of health care in the U.S. system. Even from birth, we do not provide the same level of care to all pregnant women, nor do all babies have the same chance of surviving their first year in America. In my book, Unraveling U.S. Health Care, I researched all fifty states for health metrics, including infant mortality statistics and in one area of the country, infant mortality was as poor as it is in developing countries (12.6 deaths per 100,000 babies for the District of Columbia) Only in a hand full of states was the infant mortality rate equal to European standards, of 5 or fewer deaths per 100,000 infants. Health care workers do understand and are alarmed about this dramatic difference in a basic health care outcome in the country; however, it seems much of the population is uninformed. A basic measurement for health is infant care and reducing the chance of infant death.
Another health care measure is degree of healthy living, as measured by the DALE or Disability Adjusted Life Expectancy, which measures the number of years an American can expect to live healthily, able to move around, and do their activities of daily living. In other words, how many years you can expect to be reasonably free of impairment from chronic disease. The World Health Organization, developer of this index ranked Japan as the number one country for living longest in good health to an average age of 74.5 in the year 2,000. Though the earthquake and tsunami disaster may have some impact on this in the future, the Japanese have a national health care system designed to provide primary care for their population. The United States ranked below all other developed nations in these criteria, with a Dale index of 70 years. Women are expected to be healthy to age 72.6 (true in my Mom’s case), and American men are only healthy to age 67.5. Wake-up call for boomers born in 1957 or later, you are not eligible for full Social Security benefits (under current standards) until age 67, so guys, just about the time you are expected to lose your quality of life.
The ability to live free of chronic disease is an indication of the effectiveness of a health care system and how it identifies population needs and deploys successful interventions. The U.S. health care system has been less focused on primary care, largely because clinician reimbursements and the high cost of medical school have driven more practitioners into specialty care, which treats disease, but is not geared for prevention of chronic disease. One of the provisions of the 2010 health care reforms is the Medical Home provision in Medicare, which attempts to correct the primary care problem by paying clinicians more to be the primary care provider. This concept is a start in the right direction, but as a nation we need to have more health care incentives for primary care, which prevents chronic diseases from birth through life expectancy. Only through this process can we hope to reduce the incidence and associated costs, both social and economic of chronic disease like Type II Diabetes, hyper tension, and heart disease.
Cost of Delaying Treatment
As cited above, the United States had the poorest score for healthy life expectancy of any industrialized country, literally at the bottom, yet we spend 25% more than any other country in the world. The only way we are going to be able to change this result is to build efficiency into health care delivery and improve basic preventive and primary care.
Arguments about a person’s right to health care miss the Titanic-size glacier that pummels U.S. hospital systems, which is EMTALA, the Emergency Medical Treatment Act which requires all hospitals to treat patients, regardless of their ability to pay for services. States with huge uninsured populations, like Texas, with over 25% lacking any insurance , and half of those people are working for employers who do not provide any medical insurance . Not only do those people lack access to primary care, they appear at the hospital emergency department in advanced stages of chronic disease, which must be treated. This is not an effective way to deliver health care as a nation. Hospitals are designed to treat the acutely ill, not to provide primary care. Much discussion has occurred around the health care safety net for the nation, which directly addresses the ability of these hospital systems to continue to provide free care and pass those un-reimbursed charges on to full paying customers, enrolled in private sector health care plans.
Pass-Through Costs in the Health Care System
To those who complain about providing health insurance for the uninsured, a significant portion of the insurance premium these individuals already pay is based on reimbursing hospitals for under payment serving the uninsured and to a lesser extent, Medicare and Medicaid patients. By deferring treatment in the form of primary care, the nation has elected to force these folks to develop worse chronic disease conditions, which are more expensive to treat, and result in premature death from preventable conditions. In health care, treating a patient earlier in the care continuum is best clinically and economically and this is the direction the nation needs to go. For all of the caterwauling about health insurance rate increases, if there is any hope of stabilizing these impacts, it must be driven by increasing patient access to early and consistent primary care. Further, to those who object to paying a portion of their taxes for the provisions of health care, you are already doing so, by paying more than any other country for your health insurance and the administration of your health care. A better question would be how can we reduce the cost of health care overall? Should be continue to have employers contributing to health care financing or go the European route of having the individual be responsible? And finally, health insurance is a financing tool and not a delivery system for health care. We need to improve how we provide basic health care, including disease surveillance, continuity of care for those with chronic disease, and assurance of quality care throughout the country, not just for the lucky few who live close to centers of excellence.
Moving Forward
The 2010 health care mandates attempt to address these concerns in a number of ways, including improving access to primary care by subsidizing health insurance purchasing for small businesses and individuals and thus increasing the number of people who have health insurance and thereby the ability to obtain care. The Medical Home provisions are a start to addressing the access problem that seniors have with Medicare, which pays so little to doctors providing the care. And the Accountable Care Organization standards will pay health care systems more money for high quality patient outcomes in targeted areas for Medicare. FYI, changes in Medicare become a part of the private sector as well, so health care reporting of patient outcomes for Medicare, will also be reflected in the rest of the nonmilitary (Veterans Administration has its own health care system)population. None of these components of the 2010 reforms will go away, but further wrangling will continue on standardization of care for the health insurance purchasing cooperatives and the insurance purchasing subsidies. In a worst case scenario congress may choose not to fund the subsidies to help people buy medical insurance, which would of course result in tax penalties on all of the private sector who decide they cannot afford to buy the insurance. But then again the United States is famous for its unfair tax policies which tax the poor and middle-class much more than the wealthy. Just remember any deferment of health care access and treatment now will result in more serious chronic diseases later, which we will pay for, by increased hospital charges apportioned across the private sector insurance payers and higher costs for government health care programs.
This article was written by Roberta E. Winter, MHA, MPA an independent health care consultant and journalist and may be reprinted with her permission.
